What is the treatment for supportive otitis media?

Treatment of Suppurative Otitis Media

For chronic suppurative otitis media with perforated tympanic membranes in patients 12 years and older, topical ofloxacin otic solution (10 drops twice daily for 14 days) is the FDA-approved treatment of choice. 1

Diagnosis and Classification

Suppurative otitis media refers to otitis media with purulent discharge, which can present as:

• Acute otitis media with perforation and otorrhea - requiring systemic antibiotic therapy 2, 3
• Chronic suppurative otitis media (CSOM) - persistent drainage through a perforated tympanic membrane requiring topical therapy 1
• Acute otitis media with tympanostomy tubes and otorrhea - managed with topical antibiotics 1, 4

Treatment Approach by Clinical Scenario

Chronic Suppurative Otitis Media (Perforated Tympanic Membrane)

Topical antibiotic therapy is the primary treatment:

• Ofloxacin otic solution 0.3%: 10 drops (0.5 mL) into affected ear twice daily for 14 days in patients ≥12 years 1
• Warm the solution by holding bottle in hand for 1-2 minutes before instillation 1
• Patient should lie with affected ear upward, pump tragus 4 times after instillation, and maintain position for 5 minutes 1
• This targets common pathogens: Pseudomonas aeruginosa, Staphylococcus aureus, and Proteus mirabilis 1

Acute Otitis Media with Tympanostomy Tubes and Otorrhea

Topical antibiotics are preferred over systemic therapy:

• Ofloxacin otic solution 0.3%: 5 drops (0.25 mL) twice daily for 10 days in pediatric patients 1-12 years old 1
• Covers Haemophilus influenzae, Moraxella catarrhalis, Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus pneumoniae 1
• Topical treatment is specifically recommended for recurrent acute otitis media with otorrhea from tympanostomy tubes 4

Acute Otitis Media with Spontaneous Perforation (No Tubes)

Systemic antibiotics remain necessary:

• High-dose amoxicillin (80-90 mg/kg/day) is first-line therapy 2, 3, 5
• This increased dosage (from previous standard of 40-45 mg/kg/day) addresses drug-resistant Streptococcus pneumoniae while achieving effective middle ear fluid concentrations 5
• Alternative agents for treatment failure after 48-72 hours include: 2, 3, 5
  • Amoxicillin-clavulanate (high-dose)
  • Cefuroxime axetil
  • Intramuscular ceftriaxone

Pain Management

Analgesia is paramount regardless of antibiotic use:

• Acetaminophen or ibuprofen should be used for pain control, especially during the first 24 hours 6, 3
• Pain relief should be addressed in all cases of suppurative otitis media 2, 6

Common Pitfalls to Avoid

Do not use systemic antibiotics for chronic suppurative otitis media when topical therapy is appropriate - topical fluoroquinolones provide superior local concentrations and avoid systemic antibiotic resistance 1, 4

Do not use ototoxic drops (aminoglycosides) in patients with tympanic membrane perforation - fluoroquinolones like ofloxacin are non-ototoxic and safe for middle ear exposure 1

Avoid watchful waiting in suppurative cases - unlike uncomplicated acute otitis media where observation may be appropriate, active purulent drainage requires antimicrobial therapy 2, 6

Monitoring and Follow-Up

• Reexamine patients who fail to improve after 48-72 hours of appropriate therapy 3, 5
• Consider culture of drainage if treatment fails to guide antibiotic selection 4
• Refer to otolaryngology if chronic suppurative otitis media persists despite appropriate topical therapy or if complications develop 2, 3